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Monitoring Intraoperative Blood Lactate Levels: Implications for Cardiopulmonary Bypass

Monitoring Intraoperative Blood Lactate Levels: Implications for Cardiopulmonary Bypass. Maggie Savelberg B.Sc.(H), Perfusionist Fellow London Health Sciences, London, Ontario. 2. Outline:. Objective: Marker for Adequate Perfusion . 1. Solution: Lactic Acidosis .

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Monitoring Intraoperative Blood Lactate Levels: Implications for Cardiopulmonary Bypass

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  1. Monitoring Intraoperative Blood Lactate Levels: Implications for Cardiopulmonary Bypass Maggie Savelberg B.Sc.(H), Perfusionist Fellow London Health Sciences, London, Ontario

  2. 2 Outline: Objective: Marker for Adequate Perfusion 1 Solution: Lactic Acidosis Study: Patient Selection/Methods 3 Study: Results/Conclusion 4

  3. Challenge • Periods of • acute tissue • hypoperfusion: • Poor venous return - Low volumes/flows • Patient anatomy • Surgical technique • Circulatory arrest • Hemodilution Solution Function Objective: Appropriate Marker for Adequate Perfusion Cardiopulmonary Bypass Monitoring of intraoperative lactate levels & acid/base status leading to therapeutic intervention to improve post-operative course. Allow adequate systemic oxygenation and perfusion during cardiac surgical procedure.

  4. Lactic Acidosis • Lab Abnormalities • ↑ Lactate > 2.0mmol/L • ↓ HCO3- / BE • ↓ Arterial pH • ↑ Anion gap Metabolic Acidosis Hyperlactatemia Lactic Acidosis Solution: Clinical Definitions & Significance? vs • Lab Abnormalities • ↑ Lactate >2.0 mmol/L Mild pH ≥ 7.35 La- 2.0-5.0 Severe pH ≥ 7.35 La- > 5.0 • Difficult to identify • Lactic acidosis better • correlated with • in-hospital mortality • Easily identified • -Chart & Monitor • Substitute marker Demers et al., Ann of Thorac Surg 2000;70:2082-2086 Lee et al., Emerg Med J 2008;25:659-665

  5. 1,259 patients 18% Lactate >4.0mmol/L 28 %♀ 72%♂ 82% Lactate <4.0mmol/L Study: Patient Selection & Methods 1,376 patients - Exclusions 79% CABG Sex Surgery 17% Valve

  6. Identification ? Lactic Acidosis resulting - protonated transporters fail ↑La/H+ - morbidity & mortality ↑ - 11% mortality rate vs 1.4% when lactates rise over 4 mmol/L3 ↓ pH - upregulation anaerobic metabolism ↓ vascular removal Normal Range pH normal Lactate (mmol/L) 1 2 3 4 5 6 7 8 9 10 Correction Zone It is here – intraoperatively where patient outcome can be improved by determining the cause and correcting hypoperfused states. 3Demers et al., Ann of Thorac Surg 2000;70:2082-2086

  7. Net Effect ↑ tissue perfusion Prevention & Treatment of Lactic Acidosis ↓ Oxygen Demand ↑ Blood pH ↑ Tissue Oxygenation Cause ↑ Flow rate ↑ Mechanical Ventilation ↑FiO2 ↑Hgb ↑Sedation Hypothermia NaHCO3 Tissue Hypoxia CHEST 2000; 117:260-267

  8. Perfusion • - Communicate • our difficulties • - Changes • Understanding • Willingness to accommodate Anesthesia Surgeon Summary: Intercollaborative Team Effort Taken From: Google Imagies at http://images.google.ca

  9. Thank You !! Questions or Comments ?

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